On Field Management: On Field Management: Athletic Emergencies Athletic Emergencies

Jim Ellis, MD, FACEPJim Ellis, MD, FACEP

Faculty, Primary Care Sports Faculty, Primary Care Sports Medicine Fellowship ProgramMedicine Fellowship Program

Steadman Hawkins Clinic of Steadman Hawkins Clinic of the Carolinasthe Carolinas

Why we do what we do Why we do what we do

On October 24, 1971 Chuck Hughes On October 24, 1971 Chuck Hughes of the Detroit Lions went across the of the Detroit Lions went across the middle on a pass play and collapsed. middle on a pass play and collapsed. Legendary LB Dick Butkus frantically Legendary LB Dick Butkus frantically waved to the sideline for help. waved to the sideline for help. Despite the efforts of the training Despite the efforts of the training staff, he died of a “heart attack” and staff, he died of a “heart attack” and remains the only on field death in the remains the only on field death in the history of the NFL.history of the NFL.

ObjectivesObjectivesKnow the risks of the sport you cover Know the risks of the sport you cover

Know your specific role/responsibilityKnow your specific role/responsibility

Know your players’ illnessesKnow your players’ illnesses

Know what equipment to haveKnow what equipment to have

Know the Emergency Action PlanKnow the Emergency Action Plan

ATLS, ACLS, “ASLS”ATLS, ACLS, “ASLS”Advanced Sports Life SupportAdvanced Sports Life Support

AirwayAirwayBreathingBreathingCardiacCardiacCirculationCirculationCervical SpineCervical SpineConcussionConcussionConditions/EnvironmentConditions/EnvironmentCrisis Management/DisasterCrisis Management/DisasterDiabetesDiabetes

Airway ProblemsAirway Problems

Direct TraumaDirect Trauma– Anterior neck trauma Anterior neck trauma

Indirect TraumaIndirect Trauma– Severe concussion can lead to Severe concussion can lead to

unprotected airwayunprotected airway– High cervical spine injuryHigh cervical spine injury

Airway EvaluationAirway Evaluation

Is the player talking?Is the player talking?

Is he tachypneic or agonal?Is he tachypneic or agonal?

What is the pulse ox?What is the pulse ox?

EMS bring pulse ox!EMS bring pulse ox!

Airway - MaintainableAirway - Maintainable

Supplemental oxygenSupplemental oxygen

Chin lift or jaw thrust (for c-spine)Chin lift or jaw thrust (for c-spine)

Nasal or oral airwayNasal or oral airway

Bag-valve-mask/pocket mask/barrier Bag-valve-mask/pocket mask/barrier

Airway EvaluationAirway EvaluationUnmaintainableUnmaintainable– Airway is inadequate with basic Airway is inadequate with basic

supportsupport– Procedural intervention is requiredProcedural intervention is required– Must remove facemask to have Must remove facemask to have

unencumbered access to the unencumbered access to the airway on anyone immobilizedairway on anyone immobilized

– Need Need Advanced Life SupportAdvanced Life Support EMS EMS unit at high risk eventsunit at high risk events

Endotracheal IntubationEndotracheal Intubation

The right personThe right person

The right equipmentThe right equipment

The right drugsThe right drugs

The right plan for the difficult airwayThe right plan for the difficult airway

AnatomyAnatomy

Airway AdjunctsAirway Adjuncts

Intubating StyletIntubating Stylet

Lighted StyletLighted Stylet

LMA *great tool for the airway noviceLMA *great tool for the airway novice

Intubating LMAIntubating LMA

Levitan Fiberoptic ScopeLevitan Fiberoptic Scope

LMA and Intubating LMALMA and Intubating LMA

Surgical AirwaySurgical Airway

Unsuccessful endotracheal intubationUnsuccessful endotracheal intubation

Mandibular fractureMandibular fracture

Anterior neck traumaAnterior neck trauma

Laryngeal fractureLaryngeal fracture

StridorStridor

Surgical AirwaySurgical Airway

Know the anatomyKnow the anatomy

Know the equipmentKnow the equipment

Know the procedureKnow the procedure

2002 Super Bowl2002 Super Bowl

Kurt Warner played with a laryngeal Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kitfracture – sideline cricothyrotomy kit

2004 Al Lucas2004 Al Lucas

Arena League player went down Arena League player went down headfirst on a kick-offheadfirst on a kick-off

Evaluated by MD and ATC on FOPEvaluated by MD and ATC on FOP

While being loaded into the While being loaded into the ambulance, stopped breathing (within ambulance, stopped breathing (within 10 minutes of injury)10 minutes of injury)

Died from airway compromise due to Died from airway compromise due to C1/C2 fracture and concussion despite C1/C2 fracture and concussion despite using an LMA for airwayusing an LMA for airway

1997 Reggie Brown1997 Reggie Brown

Lions linebacker injured vs JetsLions linebacker injured vs Jets

C1/C2 fracture with CHIC1/C2 fracture with CHI

Airway compromise from aboveAirway compromise from above

On field mouth to mouth and BVMOn field mouth to mouth and BVM

Response saved his life and had Response saved his life and had remarkable post op recoveryremarkable post op recovery

Breathing ProblemsBreathing Problems

Massive HemothoraxMassive Hemothorax– Load and Go!Load and Go!

Tension PneumothoraxTension Pneumothorax– Use pulse oximetry for helpUse pulse oximetry for help– Large bore IV catheter(14 gauge)Large bore IV catheter(14 gauge)– 22ndnd intercostal space, midclavicular intercostal space, midclavicular

lineline– LEAVE IT IN!LEAVE IT IN!

2001 Drew Bledsoe2001 Drew Bledsoe

Patriots QB was driven into the Patriots QB was driven into the ground on the sidelineground on the sideline

Was short of breath after the gameWas short of breath after the game

Taken to Mass General Hospital and Taken to Mass General Hospital and had a chest tube inserted to reinflate had a chest tube inserted to reinflate his lung and an autotransfusionhis lung and an autotransfusion

Tom Brady became the starterTom Brady became the starter

2008 Lauren Chang2008 Lauren Chang

Cheerleader accidently kicked in the Cheerleader accidently kicked in the chestchest

Had collapsed lungs - bilateralHad collapsed lungs - bilateral

Died from tension pneumothoraxDied from tension pneumothorax

Breathing ProblemsBreathing ProblemsAsthmaAsthma– Know your playersKnow your players– Nebulizer vs inhaler (use a spacer)Nebulizer vs inhaler (use a spacer)– Keep an extra MDI (inhaler)Keep an extra MDI (inhaler)– Make sure EMS gives the right Epi dose Make sure EMS gives the right Epi dose

SQ/IM (1:1000) vs IV (1:10,000)SQ/IM (1:1000) vs IV (1:10,000)– Can use Epi-Pen if needed (same dose Can use Epi-Pen if needed (same dose

as allergic reaction 0.3cc)as allergic reaction 0.3cc)– Peak Flow Meter (know their baseline)Peak Flow Meter (know their baseline)

2001 Rashidi Wheeler2001 Rashidi Wheeler

Northwestern football playerNorthwestern football player

Died secondary to asthmaDied secondary to asthma

Known asthmatic in difficult workoutKnown asthmatic in difficult workout

?Complicated by ephedra use?Complicated by ephedra use

Cardiac ProblemsCardiac Problems

Cardiac EtiologyCardiac Etiology– Sudden cardiac deathSudden cardiac death– Arrhythmia of unknown etiologyArrhythmia of unknown etiology– Hypertrophic cardiomyopathyHypertrophic cardiomyopathy– Commotio cordis/cardiac Commotio cordis/cardiac

concussion (hockey and baseball)concussion (hockey and baseball)– Coronary artery disease in coaches Coronary artery disease in coaches

and referees*and referees*

Cardiac InterventionsCardiac Interventions

CPR if AED is not right thereCPR if AED is not right there

AED – know where it is at all times AED – know where it is at all times and have nearby at eventsand have nearby at events

Practice run getting the AEDPractice run getting the AED

Trauma scissorsTrauma scissors

Manual defibrillator (EMS)Manual defibrillator (EMS)

Time to shock is critical!Time to shock is critical!

Cardiac InterventionsCardiac Interventions

Every minute that passes, there is a Every minute that passes, there is a 10% decrease in chance of survival.10% decrease in chance of survival.– 90% chance of survival at 1 minute90% chance of survival at 1 minute– 50% chance at 5 minutes50% chance at 5 minutes– 10% chance of survival if the initial 10% chance of survival if the initial

shock is delivered 9 minutes after shock is delivered 9 minutes after the cardiac arrest occurredthe cardiac arrest occurred

– Don’t wait for EMS Don’t wait for EMS

2005 Jiri Fisher2005 Jiri Fisher

Collapsed on the iceCollapsed on the ice

Saved with CPR and AEDSaved with CPR and AED

Key was a rapid response to a true Key was a rapid response to a true life threatening emergencylife threatening emergency

Etiology was underlying arrhythmiaEtiology was underlying arrhythmia

19961996 PolishPolish ChefChef dede MissionMission

Opening Ceremony 1996 Olympic Opening Ceremony 1996 Olympic GamesGames

Cardiac arrest on the field of play Cardiac arrest on the field of play

10,000 athletes / worldwide TV 10,000 athletes / worldwide TV audienceaudience

Defibrillated on the FOP and intubatedDefibrillated on the FOP and intubated

Transported with return of vital signsTransported with return of vital signs

Subsequent death in the hospitalSubsequent death in the hospital

2011 Al Schmidt at UGA2011 Al Schmidt at UGA

Mississippi State track officialMississippi State track official

Known CADKnown CAD

At SEC Track meet on UGA campusAt SEC Track meet on UGA campus

Witnessed cardiac arrestWitnessed cardiac arrest

Well practiced EAPWell practiced EAP

AED on site in 2 minutesAED on site in 2 minutes

Survived to discharge neuro intactSurvived to discharge neuro intact

Other serious cardiac eventsOther serious cardiac events1988 – Pete Maravich(NBA) 1988 – Pete Maravich(NBA) congenital coronary arterycongenital coronary artery1990 – Hank Gathers(NCAA) HCM1990 – Hank Gathers(NCAA) HCM1993 – Reggie Lewis(NBA) HCM 1993 – Reggie Lewis(NBA) HCM 1998 – Chris Pronger(NHL) commotio1998 – Chris Pronger(NHL) commotio2003 – Marc Vivien-Foe(soccer) SCD2003 – Marc Vivien-Foe(soccer) SCD2004 – Sergei Zholtok(NHL) HCM2004 – Sergei Zholtok(NHL) HCM

Other serious cardiac eventsOther serious cardiac events2005 – Jaxon Logan(NCAA) commotio2005 – Jaxon Logan(NCAA) commotio2005 – Thomas Herrion(NFL) 2005 – Thomas Herrion(NFL) HCM/CADHCM/CAD2007 – Damien Nash(NFL) 2007 – Damien Nash(NFL) arrhythmia of unknown etiologyarrhythmia of unknown etiology2007 – Antonio Puerta(soccer) SCD2007 – Antonio Puerta(soccer) SCD2011 – Wes Leonard(BB) SCD/?HCM 2011 – Wes Leonard(BB) SCD/?HCM

Circulation ProblemsCirculation ProblemsAbdominal Trauma/HemorrhageAbdominal Trauma/Hemorrhage– Splenic or liver injurySplenic or liver injury– Don’t confuse with dehydrationDon’t confuse with dehydration– High index of suspicionHigh index of suspicion– Life/limb threatening hemorrhageLife/limb threatening hemorrhage– Two large bore IV’sTwo large bore IV’s– Load and go (nearest Load and go (nearest appropriateappropriate

facility)facility)

2006 Chris Simms2006 Chris SimmsSeptember game vs PanthersSeptember game vs PanthersMultiple hard hitsMultiple hard hitsNo specific complaint of LUQ painNo specific complaint of LUQ painTreated for dehydrationTreated for dehydrationRuptured spleenRuptured spleenSurgery at St. Joe’s Hospital (< 1 Surgery at St. Joe’s Hospital (< 1

mile)mile)

1989 Clint Malarchuk1989 Clint MalarchukNHL goalie with skate to the neckNHL goalie with skate to the neckLife threatening hemorrhageLife threatening hemorrhageDirect pressure and rapid transportDirect pressure and rapid transportWent directly to OR for vascular Went directly to OR for vascular

surgery and survivedsurgery and survived

Circulation ProblemsCirculation ProblemsSickle Cell TraitSickle Cell Trait

- easy to diagnosis with a simple - easy to diagnosis with a simple screening blood test screening blood test - 10 known deaths since 2000- 10 known deaths since 2000- 8-10% of black population- 8-10% of black population- NATA policy statement- NATA policy statement- NCAA ?mandatory testing- NCAA ?mandatory testing

Circulation ProblemsCirculation ProblemsSickle Cell TraitSickle Cell Trait

- Identify high risk activities- Identify high risk activities

- common in off- or pre-season- common in off- or pre-season

- monitor first few workouts- monitor first few workouts

- ease into preseason conditioning- ease into preseason conditioning

- SCT muscle pain and weakness - SCT muscle pain and weakness

- dehydration cramps/”locking up”- dehydration cramps/”locking up”

2008 Ereck Plancher2008 Ereck PlancherCollegiate athlete with known sickle Collegiate athlete with known sickle

cell traitcell traitOff-season programOff-season programStrenuous workoutStrenuous workoutExhibited difficultyExhibited difficultyDied on the fieldDied on the field

Sickle Cell Trait - deathsSickle Cell Trait - deathsPreston Birdsong –TTU 2000Preston Birdsong –TTU 2000DeVaughn Darling – FSU 2001DeVaughn Darling – FSU 2001Aaron Richardson – BGU 2004Aaron Richardson – BGU 2004Aaron O’Neal – Missouri 2005Aaron O’Neal – Missouri 2005Dale Lloyd – Rice 2006Dale Lloyd – Rice 2006Chad Wiley – NC A&T 2008Chad Wiley – NC A&T 2008Ja'Quayvin Smalls – 2009 WCUJa'Quayvin Smalls – 2009 WCUBennie Abram – 2010 Ole MissBennie Abram – 2010 Ole Miss

Cervical Spine InjuryCervical Spine Injury

CervicalCervical SpineSpine ImmobilizationImmobilizationClinical decisionClinical decisionStandardize approach and procedureStandardize approach and procedureHave unencumbered airway accessHave unencumbered airway accessDon’t assume that EMS knows what Don’t assume that EMS knows what

to do – you teach them how you want to do – you teach them how you want it done and practice before the it done and practice before the season (NATA video) season (NATA video)

Spinal Cord Injury Treatment Spinal Cord Injury Treatment ““OptionsOptions””

High dose steroids – High dose steroids – methylprednisolone 30 mg/kg bolus methylprednisolone 30 mg/kg bolus Maintenance dose – 5.4 mg/kg/hr Maintenance dose – 5.4 mg/kg/hr (needs to be started at hospital within (needs to be started at hospital within 3-8 hours)3-8 hours)

Hypothermia – 30 cc/kg of LR cooled to Hypothermia – 30 cc/kg of LR cooled to 37-40 degrees F should drop temp to 37-40 degrees F should drop temp to around 95. Ideal temp between 92-94.around 95. Ideal temp between 92-94.

Kevin Everett case Kevin Everett case

2007 Kevin Everett2007 Kevin EverettMade a tackle on the kickoff with his Made a tackle on the kickoff with his

head downhead downReceived cold IV fluids and steroidsReceived cold IV fluids and steroidsThe real key to his recovery was The real key to his recovery was

going to the appropriate hospital and going to the appropriate hospital and being in surgery within 2 hours being in surgery within 2 hours

ConcussionConcussionDr. Sease concussion updateDr. Sease concussion updateClinical judgment determines if Clinical judgment determines if

severity of head injury negates the severity of head injury negates the validity of the c-spine examvalidity of the c-spine exam

Always fear the concussion when Always fear the concussion when paired with the C1/C2 fracture – axial paired with the C1/C2 fracture – axial load with flexionload with flexion

If immobilizing, remove the If immobilizing, remove the facemask even if awake and talkingfacemask even if awake and talking

2006 and 2007 Trent Green2006 and 2007 Trent GreenConcussions while playing with Concussions while playing with

Chiefs (2006) and Dolphins (2007)Chiefs (2006) and Dolphins (2007)Both were significant and had Both were significant and had

prolonged recovery periodsprolonged recovery periodsWas able to return to play after Was able to return to play after

evaluation and clearanceevaluation and clearance

2000 Blaine Bishop2000 Blaine BishopTitans DB in Super BowlTitans DB in Super BowlBrief LOC / neck pain / L arm Brief LOC / neck pain / L arm

numbnessnumbnessSpinal immobilizationSpinal immobilizationTransport to hospitalTransport to hospitalFinal diagnosis – concussion/cervical Final diagnosis – concussion/cervical

strainstrainComprehensive pregame planning Comprehensive pregame planning

Conditions/EnvironmentConditions/EnvironmentHeat illnessHeat illnessHeat cramps/exhaustion/strokeHeat cramps/exhaustion/stroke33 heat related deaths in football 33 heat related deaths in football

since 1995since 1995Korey Stringer of the Minnesota Korey Stringer of the Minnesota

VikingsVikingsSteve Belcher of the Baltimore Steve Belcher of the Baltimore

OriolesOrioles

Conditions/EnvironmentConditions/EnvironmentLightning – approximately 100-120 Lightning – approximately 100-120

people die per year in the US from people die per year in the US from lightninglightning

In 2006, 5 people died at one event In 2006, 5 people died at one event during a storm (softball)during a storm (softball)

Rosbin Yuman and Lester Marrioquin Rosbin Yuman and Lester Marrioquin soccer players killed in 2001soccer players killed in 2001

Tend to the unconscious first – they Tend to the unconscious first – they usually need more electricity (AED)! usually need more electricity (AED)!

CrisisCrisis Management/Disaster Management/Disaster PlanningPlanning

Know the disaster plan/EAPKnow the disaster plan/EAPHave a written Emergency Action Plan for Have a written Emergency Action Plan for

every venue including practiceevery venue including practicePractice the EAP – docs, ATC’s, coachesPractice the EAP – docs, ATC’s, coachesIs there an evacuation plan?Is there an evacuation plan?Be familiar with the Rally PointBe familiar with the Rally PointTake care of the visiting teamTake care of the visiting teamHave a roster for roll call Have a roster for roll call

DiabetesDiabetesKnow your athletesKnow your athletesEither high or low when they are sickEither high or low when they are sickUrine dipstick is quick and easyUrine dipstick is quick and easyHigh – dipstick + for glucose and maybe High – dipstick + for glucose and maybe

ketones if DKA (Rx with NS)ketones if DKA (Rx with NS)Low – dipstick may have ketones from Low – dipstick may have ketones from

starvation but not spilling glucose (Rx with starvation but not spilling glucose (Rx with D50W or glucagon emergency kit)D50W or glucagon emergency kit)

Usually need to call EMS in either situationUsually need to call EMS in either situation

Diabetic AthletesDiabetic AthletesJay CutlerJay CutlerArthur AsheArthur AsheTy CobbTy CobbScott VerplankScott VerplankJackie RobinsonJackie RobinsonJoe FrazierJoe FrazierBillie Jean KingBillie Jean KingJoe GibbsJoe Gibbs

What EMS should have:What EMS should have:Airway equipment and suppliesAirway equipment and suppliesPortable pulse oximeterPortable pulse oximeterEnd tidal CO2 detectorEnd tidal CO2 detectorManual defibrillator/cardiac monitorManual defibrillator/cardiac monitorACLS drugsACLS drugsRSI drugs if trained MD or state allows EMS RSI drugs if trained MD or state allows EMS

to useto useSteroids if you use them for SCISteroids if you use them for SCI?Oversize backboard for football?Oversize backboard for footballDon’t assume that they have things!Don’t assume that they have things!

What you should haveWhat you should haveAirway plan – LMA, #11 blade, curved Airway plan – LMA, #11 blade, curved

hemostatshemostatsBreathing plan – 14 gauge angiocath, Breathing plan – 14 gauge angiocath,

extra inhaler, Flow Meter, Epi(1:1000)extra inhaler, Flow Meter, Epi(1:1000)Cardiac plan – know how to use AEDCardiac plan – know how to use AEDDisaster plan – be familiar with EAPDisaster plan – be familiar with EAPProcedure plan – know who should and Procedure plan – know who should and

who can do what procedurewho can do what procedureTransport plan – Transport plan – appropriateappropriate facility facility

EMS RelationshipEMS RelationshipWork closely with themWork closely with themPreseason practice of scenariosPreseason practice of scenariosLet them know what is expected of Let them know what is expected of

them, when to come out, what to dothem, when to come out, what to doDemand consistency in staffingDemand consistency in staffingRequire their best trained personnelRequire their best trained personnel

Who should do whatWho should do whatParamedics can intubateParamedics can intubateOnly physicians can do surgical airwayOnly physicians can do surgical airwayOnly physicians can needle decompress Only physicians can needle decompress

tension pneumothoraxtension pneumothoraxATC’s, MD’s, coaches, anyone with training ATC’s, MD’s, coaches, anyone with training

can use AEDcan use AEDEMT-Basic has limited training and EMT-Basic has limited training and

experience in the life threatening experience in the life threatening situationssituations

QuestionsQuestionsLife threatening athlete situations Life threatening athlete situations

exist in almost every sportexist in almost every sportAlways know who is in charge Always know who is in charge Always know who is best trained for Always know who is best trained for

a particular incidenta particular incidentAlways be prepared and be Always be prepared and be

resourceful if unusual situations ariseresourceful if unusual situations arise